Running Head: SELF-ASSESSMENT

Self-Assessment of Nursing Standards of Practice: Emergency Nursing Andrea Mygrants Ferris State University

SELF-ASSESSMENT Abstract Emergency nursing can be a complex, fast paced, and stressful career. The best way to ensure that I am giving quality emergency nursing care is to continually review the policies, laws, and standards that are in place to guide my practice. One area of importance for me is the standards of care for emergency nurses as written by the

Emergency Nurses Association (ENA). It is also important for me to not only know what these standards are, but to also identify personal goals to meet them.

SELF-ASSESSMENT Self-Assessment of Nursing Standards of Practice: Emergency Nursing The purpose of this paper is to identify and familiarize myself with the standards

of practice as defined by the Emergency Nurse Association. The ENA is an international organization that aims to represent, educate, and promote emergency nurses as a profession. They have written and maintain the Emergency Nursing Scope and Standards of Practice that I will be reviewing. In addition I will also be identifying how these standards relate to my nursing practice, and what goals will assist me in improving my practice in these standards. Standards of Practice Standard 1: Assessment The ENA states that, The emergency registered nurse collects comprehensive data pertinent to the health care consumers health and/or situation. (ENA, 2011) This standard is particularly important to me in my practice. Often times obtaining an accurate assessment takes asking many questions in combination with paying attention to the answers the patient gives, what body language they are using, and how they and their family or visitors are reacting to the entire situation. While I learned different assessment techniques in nursing school, I have also found that experience has given me an important advantage in this area. This standard is also of great importance to emergency nurses because often times ER patients have rapidly changing conditions. As an emergency nurse I have learned that not only is it important to obtain a thorough initial assessment, it is also important to monitor and re-assess my patients as their condition may change. This not only allows me to give the appropriate care and treatments, it also lets other members of the patients

SELF-ASSESSMENT care team to adjust their plan of action as well. I have had many instances of a doctor ordering a medication or treatment on a patient that I had to request be modified because the patients condition had changed. By re-assessing my patient and relaying this information, my patients receive the care they need. This standard also includes a section specific to triage, as this is a skill specific to emergency nurses. The ENA states that, The emergency registered nurse collects comprehensive data pertinent to the health care consumers health and/or situation. (ENA, 2011)

I have found that initially the triage process is difficult to grasp. As nurses we want to learn as much as we can about a patient, and then do as much as we can. This is not the case in triage. Triage involves a very focused exam and questions to find out what the chief complaint is and how critical the patients illness or injury is. I have also found that triage also involves using intuition, experience, and rapid recognition of potential life threats. It is for this reason that nurses in most ERs are not even allowed to work in triage until they have at least a year of experience. While I am proud to say that I tend to work well in the position of triage, I still think I have more to learn. I specifically need to learn how to better handle stress when we are busy and have long wait times. When the patients become upset and angry it is difficult for me not to become defensive. Standard 2: Diagnosis For the standard of nursing diagnosis, the ENA states, The emergency registered nurse analyzes the assessment data to determine the diagnoses or issues. (ENA, 2011) This standard ties in with the natural next step in emergency nursing care. Once an assessment has been made, it is important to think about possible diagnoses. Due to the

SELF-ASSESSMENT fast paced environment of the emergency room, I find it to be a rare occurance that any formal nursing diagnosis is made or written out. However, I have found that through experience with using and practicing the nursing process, I automatically formulate my diagnosis and begin to develop a plan. An instance of this may be a patient that comes into the ER presenting with difficulty breathing. While I know that this patient may have a list of possible medical

diagnoses such as pneumonia, influenza, COPD, or pulmonary embolism, I dont need to wait on a formal medical diagnosis to come up with the nursing diagnosis of ineffective breathing pattern. With this diagnosis I can begin to implement interventions such as repositioning the patient, monitoring breathing rate, depth, quality, and lung sounds, and administering oxygen as needed and ordered. Standard 3: Outcomes Identification For this standard the ENA states, The emergency registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation. (ENA, 2011) In emergency nursing, this outcome entails a lot of discussion and teaching with the patient. I have found that often times when a patient comes in to the ER the expectations that they have about what we can accomplish for them may be very different than what they are expecting. The most common example of this that comes to mind is when a patient comes into the ER complaining of chest pain. We have a standard chest pain protocol that we follow that involves obtaining a rapid ECG, blood work, a chest x-ray and giving aspirin. I then explain to patients that most of the time even if all of their tests come back negative, the physician will plan to admit them for observation. This involves repeat

SELF-ASSESSMENT ECGs, blood work, and a consultation with a cardiologist who often times will

recommend a cardiac stress test. While patients often seem overwhelmed with the depth and time commitment of this plan of care, I have found that explaining this to them up front and telling them why we have this protocol in place decreases their anxiety and increases their chances of following through with all of the testing. Standard 4: Planning According to the ENA, The emergency registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. (ENA, 2011) In reading this standard, the thing that stuck out the most to me are the importance of individualizing the plan to meet a persons needs based on many variables such as culture, religion, education level, and lifestyle. I believe that this is of special importance in the emergency room because we see such a variety of people in terms of age, culture, and severity and type of illness. While we often have specific protocols for different injuries or illnesses, it is important to me as an emergency nurse to take these protocols and then work them into a plan of care that takes into account the individual person. Standard 5: Implementation The ENA states for this standard that, The emergency registered nurse implements the identified plan. (ENA, 2011) The ENA also includes subheadings to this standard that include coordination of care, health teaching and health promotion, consultation, and prescriptive authority and treatment as it applies to advanced practice nurses working in the ER. Over the years, I have learned that a very important part of implementation in the emergency room involves getting the patient to think about what they need to do or

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accomplish once they eventually leave the ER. I always try to help them understand that their plan of care doesnt end once they leave the ER and that they need to think about how they will follow through with either admission or discharge. When I get my patients to think long term, I often find it is easier to implement our planning and even get them to assist me in implementing it as well. While I find that my nursing plans for emergency patients can be sometimes short or rushed, I have learned the importance of discussing and educating the patient about how the plan is being implemented along the way. This is also when the subheadings of coordination, health teaching, and consultation become very important as they assist in making sure implementation lasts beyond the ER visit. Standard 6: Evaluation The final standard is that, The emergency registered nurse evaluates progress toward attainment of outcomes (ENA, 2011) While I believe that this standard is very important, I also think it can sometimes be the most difficult to carry out as an emergency nurse. While I can evaluate the effectiveness of more immediate interventions such as pain medication, or oxygen therapy, it is difficult to monitor and evaluate the effectiveness of therapies and plans that are continued outside of the ER. This is also difficult in the ER because we may never see this patient again, and therefore we dont know if our treatment was effective or not. Professional Development Plan Goals I am a firm believer that nursing is a field that requires continual and active learning. I try to achieve this by keeping updated on practice changes at my job, reading

SELF-ASSESSMENT new research that is presented to me, and continuing to find education opportunities. While finishing my BSN is taking a large amount of my time presently, when I have completed this I would also like to become more involved in committees at work. I would also like to study and obtain my certification as an emergency nurse. I have also developed goals for each ENA standard. Assessment goals. Strong assessment skills are very important to my practice as an emergency nurse. To become better at assessment, I will continue to practice the Emergency Severity Index (ESI) that I have been taught to triage, and I will continue to take a refresher class every two years. I will also continue to refresh my certifications in Trauma Nurse Core Curriculum (TNCC) and Emergency Nurse Pediatric Curriculum (ENPC) every four years. These certifications are important to maintain as they contain practice updates and new information, and it refocuses me on the right way to perform assessments. Diagnosis goals. I find that as an ER nurse who works closely and constantly with physicians, it is easy to get wrapped up in medical diagnoses, and forget that my nursing diagnoses are important also. To help me strengthen my practice as a nurse, I will take at least two patients per shift and use my nursing diagnosis book to find two priority nursing diagnoses for these patients. I will do this for the next six months, then re-evaluate whether I will continue this plan or modify it.

Outcomes identification goals. One area that I find myself lacking in this area is a familiarity with community resources. Often times when I am discharging a patient, they will ask me questions about how to obtain follow up care and I dont always have an answer for them. To accomplish this goal, I plan on doing a job shadow with one of our

SELF-ASSESSMENT ER case managers. They are a great resource to our department and our patients, and I would gain a lot of information from them about how to find community resources, and then direct patients to those resources. Planning goals. While I feel that I do a good job at creating a plan of care with

my patients, I know that I can find ways to become better. One way that I have identified is to study for and obtain my certification as an emergency nurse. By having a more in depth knowledge about various emergency conditions, I will be able to better educate my patients and help them understand our plan of care for them. Implementation goals. To become better at implementation, I will begin performing a self-survey by asking my patients, What do you think I could do better in giving you nursing care? I think that this will help me in two ways. First, it will help me to receive constructive criticism on how patients perceive my ability to meet their needs. Second, it will help me to not seem rushed in their care, as is easy to do in a fast paced environment. This goal will begin immediately and will be re-evaluated in six months. Evaluation goals. As stated earlier, I sometimes find it difficult to evaluate my entire plan of care for a patient, because I only interact with them for a short time. To help me become better at evaluation, I will volunteer to perform discharge follow up calls. Our department regularly makes phone calls to patients who have been discharged from the ER to find out how we did in our care, and to answer any questions they may still have. Currently we only have one nurse who regularly does discharge calls, and our manager has offered to allow other nurses on the department to participate in this as well. I will start this goal immediately and re-evaluate its effectiveness in six months.

SELF-ASSESSMENT Action Plan

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This table includes the summary of my goals in each area and the timeframe they will be carried out in. Assessment Goals ESI- renew every two years due 10/14 TNCC- renew every four years due 2/16 ENPC- renew every four years due 4/16 Diagnosis Goals Chart audit two patients and identify two priority nursing diagnoses- Start immediately and review for effectiveness in six months Outcomes identification goals Job shadow with ER case management- call for available time with a case manager- plan for a time in between semesters, tentative 5/14 Planning goals Obtain CEN- will begin studying when finished with BSN in December 2014. Tentative test date of 6/15 Implementation goals Self-survey- Begin immediately and re-evaluate for effectiveness in six months. Evaluation goals Discharge follow up calls- begin immediately and reevaluate for effectiveness in six months.

Evaluation Plan To evaluate the effectiveness of my goals, I will keep this paper for reference and re-read and evaluate my goals once per month. During this monthly review, I will also ask one of my co-workers to read my goals, give me feedback about how I am doing

SELF-ASSESSMENT toward achieving them, and tell me what adjustments I might need to make. Finally I

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will give my list of goals to my department manager and ask her to use them in my yearly evaluation.

SELF-ASSESSMENT References

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Emergency Nurses Association (ENA). (2011). Emergency nursing scope and standards of practice. (1 ed.). Des Plaines, IL: Emergency Nurses Association.